CVS Health is building a world of health around every consumer, and we’re looking for a Utilization Management Nurse Consultant to join our team. In this remote role, you will apply clinical judgment and evidence-based criteria to review inpatient and outpatient services, collaborating with providers, authorizing care, and navigating multiple systems.
What You'll Do
- Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization and benefit management program.
- Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members.
- Gather clinical information and apply appropriate clinical criteria, guidelines, policy, procedure, and clinical judgment to render determinations.
- Communicate with providers and other parties to facilitate care and treatment.
- Identify members for referral opportunities to integrate with other products, services, or programs.
- Identify opportunities to promote quality effectiveness of healthcare services and benefit utilization.
- Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization management function.
- Work in a clinical telephone queue for 2 to 4 hours daily to secure additional information from providers for prior authorization review.
What We're Looking For
- Active, unrestricted state Registered Nurse (RN) licensure in your state of residence.
- Minimum of 5 years of relevant nursing experience.
- At least 1 year of Utilization Management experience in concurrent review or prior authorization.
- Strong decision-making skills and clinical judgment in independent scenarios.
- Proficiency with phone systems, clinical documentation tools, and navigating multiple digital platforms.
- Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.
- Associate's degree in nursing (RN).
Nice to Have
- BSN preferred.
- 1+ year of experience in a managed care organization (MCO).
- Experience in a high-volume clinical call center or prior remote work environment.
Benefits & Compensation
- Compensation: $29.10 - $62.32 per hour.
- Affordable medical plan options.
- A 401(k) plan (including matching company contributions).
- An employee stock purchase plan.
- No-cost programs including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Paid time off and flexible work schedules.
- Family leave and dependent care resources.
- Colleague assistance programs and tuition assistance.
- Retiree medical access.
Work Mode
This is a fully remote position within the United States. The schedule is Monday through Friday, 10:30am-7:00pm EST or 11:30am-8:00pm EST.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
